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OUR MISSION: TO REDUCE THE BURDEN OF CARDIOVASCULAR DISEASE
Prof. Guido Grassi
2007 ESH/ESC Hypertension Guidelines Novelties
The 2007 European Guidelines on Hypertension have been presented at the main Scientific Meetings of the two Societies participating at the Task Force Guidelines Committee, i.e. the European Society of Hypertension and the European Society of Cardiology. The full version is published in the official scientific journals of the two societies (1-2). The new Guidelines emphasise the relevance of the assessment of total cardiovascular risk and underline the importance of therapeutic strategies aimed at effectively controlling high blood pressure and based on combination drug treatment.
The first Guidelines for the management of hypertension have been developed about 30 years ago by the American Joint National Committee (3). They were then followed, one year later, by the World Health Organisation / International Society of Hypertension Guidelines (4). Since then Guidelines on Hypertension have been revised and updated every 4 to 6 years with the aim at incorporating in the Document the larger amount of information on the pathophysiology, diagnosis and treatment of the hypertensive disease. In 2003, for the first time, the European Society of Hypertension and the European Society of Cardiology agreed to prepare and publish a Joint Guidelines document, which became the scientific paper most frequently quoted in the past few years (5). The 2003 Guidelines have been updated and largely rewritten in the 2007 document, whose elements of novelty are summarised in Table 1.
The 2007 Guidelines confirm the definition and classification of essential hypertension based on blood pressure values already mentioned in the 2003 Guidelines, underlining the importance of different types of blood pressures as well as of the assessment of end organ damage and total cardiovascular risk. In the diagnostic evaluation of the patients, 2007 Guidelines confirm the list of the examinations already mentioned in the 2003 version. The only exception is the disappearance of protein C levels assessment, which appears, with only few specific exceptions, as a marker of inflammation that is too generic to be employed as a prognostic tool. Another major element of novelty comes from the statement that a large proportion of benefits comes from the blood pressure reduction “per se” and that protection of treated hypertensive patients largely comes from the blood pressure reduction “per se” and only in part from the type of drug treatment.
One of the peculiar features of the ESH/ESC 2007 Guidelines on hypertension is the relevance assigned to the assessment of subclinical organ damage, given the evidence that this evaluation is of crucial importance for assessing total cardiovascular risk. Some of the organ damage measures are of routine evaluation (EKG, echocardiography, microalbuminuria, creatinine) while other, more expensive measures, are recommended for a more-in-depth assessment of cardiovascular risk reserved to particular clinical conditions. However, new Guidelines stress the importance of microalbuminuria as a simple, feasible, cheep and precise test for evaluating organ damage, taking into account its ability to predict in the long-term period both renal outcome and cardiovascular events. Two “new” measures for the assessment of end-organ damage have been recommended, i.e. the ankle-brachial ratio and the pulse wave velocity. Both these measures, which reflect alterations in arterial stiffness, have been shown to represent sensitive and accurate markers of the atherosclerosis disease. Their use, however, has to be implemented in the next few years. Another key aspect of 2007 Guidelines refers to the recommendation that organ damage should be assessed not only before treatment but also during treatment in order to closely monitor throughout the years the effects of antihypertensive drug treatment on structural and functional alterations of the cardiovascular system. This indication is of particular relevance, given the evidence that an improvement in organ damage closely mirrors a reduction in cardiovascular events, thereby indicating a greater cardiovascular protection.
Evidence accumulated over the years has conclusively shown the importance of blood pressure reduction “per se” for protecting the hypertensive patient. Blood pressure thresholds for initiating treatment are set at values : 140/90 mmHg in the majority of hypertensive patients, but below this threshold in high risk individuals. This is a difference from the recommendations made in previous Guidelines (5), emphasising the importance of the so-called “flexible threshold” for treatment, which is based not only on the elevation of blood pressure values but also on the assessment of total cardiovascular risk profile. This latter parameter thus becomes crucial for treatment strategy. The 2007 Guidelines make three other key points for treatment. First, they affirm that non-pharmacological measures for treatment of hypertension, based on lifestyle changes, should be implemented mainly in the early phases of the therapeutic intervention preceding the pharmacological approach. Second, 2007 Guidelines emphasise the importance of blood pressure reduction “per se” for lowering cardiovascular morbidity and mortality associated with hypertension. Finally, the 2007 Guidelines touch another issue of major clinical relevance, namely the need to have an optimal or near-optimal blood pressure control during treatment. This goal should be pursued by making use of combination drug treatment, which should be used not only when monotherapy is ineffective but also as first-line treatment option. The rationale for this statement is based on the evidence that achievement of a full blood pressure control in a shorter time period means greater cardiovascular protection (6). Among the combination treatments available, the 2007 ESH/ESC Guidelines recommend the following ones (Figure 2):
A final “hot therapeutic” issue deserves to be briefly mentioned, namely the position of beta-blockers as antihypertensive drugs. Although the British Guidelines (7) seem not to consider beta-blockers as first line treatment, the 2007 ESH/ESC Guidelines still retain these compounds as first line antihypertensive drugs particularly in those patients in which the blood pressure elevation is associated with clinical conditions such as angina, previous myocardial infarction and heart failure.
The 2007 ESH/ESC Guidelines represent an updated and detailed document on the clinical relevance of high blood pressure, cardiovascular risk profile and antihypertensive treatment. They also represent a useful guide for daily clinical practice. Successful implementation of the 2007 ESH/ESC Guidelines in current clinical practice will hopefully allow to promote an improvement in the disease management and in patients’ outcome.
Elements of novelty in the 2007 ESH/ESC Guidelines
Metabolic SyndromeRelevance of subclinical damageImportance of Renal dysfunction (GFR, creatinine clearance)MicroalbuminuriaLeft ventricular concentric remodeling associated with increased cardiovascular riskMultidistrictual organ damage assessmentArterial distensibility and ankle/brachial ratioRelevance of end-organ damage assessment before and during treatmentHeart rate as possible prognostic marker in hypertension
Figure 2. Possible combinations between some classes of antihypertensive drugs according to 2007-ESH/ESC Guidelines. The preferred combinations in the general hypertensive population are represented as thick lines. The frames indicate classes of agents proven to be beneficial in controlled intervention trials.
The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.
1. Mancia G, De Backer G, Dominiczak A, et al. 2007 Guidelines for the Management of Arterial Hypertension: The Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). J Hypertens. 2007;25:1105-1187. 2. Mancia G, De Backer G, Dominiczak A, et al. 2007 Guidelines for the management of arterial hypertension: The Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). Eur Heart J 2007;28:1462-1536. 3. Joint National Committee. Joint National Committee Report on Detection, Evaluation and Treatment of high blood pressure. JAMA 1977;237:255-261. 4. WHO Expert Committee. Arterial Hypertension, Geneva: World Health Organization. Tech Rep Series 1978;628:7-58. 5. Guidelines Committee. 2003 European Society of Hypertension-European Society of Cardiology guidelines for the management of arterial hypertension. J Hypertens 2003; 21:1011–1053 6. Julius S, Kjeldsen SE, Weber M, Brunner HR, Ekman S, Hansson L, Hua T, Laragh J, McInnes GT, Mitchell L, Plat F, Schork A, Smith B, Zanchetti A; VALUE trial group. Outcomes in hypertensive patients at high cardiovascular risk treated with regimens based on valsartan or amlodipine: the VALUE randomised trial. Lancet 2004 ;363:2022-2031. 7. Hypertension: management of hypertension in adults in primary care NICE/BHS. June 2006.
Prof. G. Grassi Milan, Italy Past-Chairman of the WG “Hypertension and the Heart", and ESC Member of the ESH/ESC Task Force Guidelines Writing Committee